Monday, 8 November 2010

MRCP revision battle 43.1: Post renal-transplant complications

I'll admit it: I've been avoiding renal revision.  It's complicated I never understand it and it leaves me internally angry.  However dear friends I'm afraid the time has come to face a fully renal day.  On the menu is...

MRCP revision battle 43.1: Post renal-transplant complications
MRCP revision battle 43.2: Polycystic kidney disease and renal cysts
MRCP revision battle 43.3: Renal tubular acidosis
MRCP revision battle 43.4: Haematuria
MRCP revision battle 43.5: Renal calculi
MRCP revision battle 43.6: Focal Segmental Glomerulonephritis
MRCP revision battle 43.7: Acute renal failure

MRCP revision battle 43.1: Post renal-transplant complications

A kidney transplant can give a renal patient their life back as it frees them from endless dialysis sessions.  However, with kidney transplants come the risk of rejection/failure, complications and the burden of immunosupression...


Acute rejection (less than 6 months post graft) presents as rising creatinine, possibly with fever and graft pain.  Biopsy would show immune cell infiltration.  Treatment is with high dose IV methylprednislone

Chronic rejection (greater than 6 months post graft) presents as gradually rising creatinine and proteinuria.  Biopsy would show fibrosis.  There is no effective treatment.

Overall graft survial is around 90% at 1 yr, 70% at 5 yrs and 50% at 10 yrs.

Non-renal complications

  • Non-Hogkins Lymphoma - 20-50x increased risk due to ciclosporin use
  • Skin cancer - 5-20x increased risk due to azothioprine
  • Widespread warts/fungi/herpes zoster due to T cell supression by immunosupressives
  • Cardiovascular disease - 10-20x increased risk
  • CMV - give oral ganciclovir
  • Pneumocystis carini pneumonia - give cotrimoxazole prophylaxis for first 6 months post transplant
  • if previous TB give isoniazid for first year
  • gout
  • Diabetes - develops in 3-5%, ?due to tacrolimus

The common immunosupressants

  • Ciclosporin
    • inhibits T cell phosphatase calcineurin
    • can cause tremor, hypertension, gum hypertrophy
  • Tacrolimus
    • decreases T cell activation
    • ?risk of diabeets
  • Azothioprine
    • contraindicated with allopurinol as risk of life-threatening bone marrow supression
    • is an anti-proliferation drug 
    • TPMT test can be used to look for patients prone to toxicity
    • side effects include bone marrow supression and pancreatitis.
  • Mycophenolate
    • anti-proliferative
    • causes diarrhoea
  • Sirolimus
    • blocks IL2 so inhibits T cell division
    • can provoke hyperlipidaemia

Now lets move on to polycystic kidney disease....